1. Task-Shifting in HIV/AIDS Care in a Rural District of Malawi Some successes and lessons learnt from Thyolo Moses Massaquoi, Rony Zachariah, Ulrike von Pilar Médecins Sans Frontières (Operational research) – Brussels District Health Services, Thyolo, Malawi Ministry of Health and Population, Malawi

2. MALAWI Population 13 million Adult prevalence14,1% HIV-infected people 900,000 Life expectancy39 yrs TB cases/year 25, 000 (77%HIV+) Hospital admissions 70% HIV+ HIV/AIDS - deaths/year90,000 HIV/AIDS & TB: A major burden on health services!

3. MALAWI Shortage of health staff Vacant positions : Nursing staff 64% Clinical officers 53% Doctors / Specialists 85-100% Nurse/health facility < 1.5 nurses per health facility in 15/29 districts Doctors/district 10 districts with no MOH doctor. 4 districts have no doctor at all “2004: “Crisis” / Collapse of the health sector”

4. Staff per 100,000 population (WHO, 2004) Cadre South- Africa LesothoMalawiMozam- bique USAUK Doctors 74,3522.6247222 Nurses 39362.656.4209011,170

5. Background: Thyolo district

6. OBJECTIVES To highlight some successes and lessons learnt in “task shifting” to achieve Universal ART Access in Thyolo.

7. METHODS (1) Scale up: HIV-testing/ Clinic services CT: Increase sites: from 3 to 26 (trained lay PLWA counsellors) HIV/AIDS clinics: Drastically improve efficiency of “delivery systems” particularly for ART.

8. METHODS (2) : Clinics “One track” doctor centred  “multiple flow tracks” Screening & track allocation - Nurse Slow track - Medical assistant Complicated opportunistic infections (OI) Side effects/referred patients Medium track - Nurse Less severe OI (eg candida, diarrhoea) ART initiation /ART follow up (< 1month) Fast track - PLWA counsellor Stable patients & drug refills Doctor/Clinical officer – Supervision and support

9. METHODS (3) Community: Involvement & Activities Community network : (Volunteers/PLWA’s) –Treatment : diarrhoea, fever, oral thrush…. –Community based counselling (ART) –Support to family care givers at home –Referral : drug reactions and “risk signs”. –Cough screening (TB) –Social mobilisation.

10. METHODS (4) Community: Volunteers

11. METHODS (5) Community: Home care “kit”

12. METHODS (6) Community: Nurses

13. RESULTS (1) HIV- testing Period Jan 2003 – Dec 2006 HIV-tested 146,411 HIV-positive 36, 603 PLWA counsellors 124,449 (>85%) Over three quarters of all CT in the district done by PLWA counsellors !

14. CT: Average/Month Thyolo, Malawi “Task shifting” : Nurses to PLWA’s Task shifting increased CT capacity by 5 times

15. RESULTS (2) Consultations / Month Task shifting to medical assistants, nurses & PLWA’s Partial task shifting to medical assistants Three health centres ++

16. RESULTS (3) ART: New inclusions/Month Three health centres ++ “Partial” task shifting to medical assistants Task shifting to medical assistants, nurses & PLWA’s Task shifting increased ART inclusion capacity by 4 times

17. ART - Thyolo Universal Access - Dec 2007 ? ART Target: 10,000 (+-1000) On ART 6285 (March 2007) ART initiations/Month 400 Target Nov 2007 Without task shifting, this target would only have been achieved by 2012 !

18. RESULTS (4) Community: Active TB case finding (Jan 2003-Dec 2004) Chronic cough:  3 weeks No referred (chronic cough) 806 No with Smear + PTB 161 (20%) Annual TB incidence (Households) 1997/100,000 Reported TB incidence (Malawi) 265/100,000 “Active” cough screening detects 8 times more infectious TB cases !

19. RESULTS (5) Antiretroviral treatment (ART) Period Jan 2003-Dec 2004 Total placed on ART 1634 with community support 895 (55%) without community support 739 (45%) Compare: ART outcomes among patients living in areas with and without community support

21. CONCLUSIONS (1) Universal access: Develop a Public Health ART scale-up model, standardize, keep it simple, be inclusive, use lower cadres & community. “Good for many” instead of “best for a few”

22. CONCLUSIONS (2) Be innovative.. Challenge established practices, rules and regulations “professional turf protection”

24. ACKNOWLEDGEMENTS PLWA associations and groups District health services, Thyolo Ministry of Health - Malawi Financial support: –G.D of Luxembourg, –DFID, NORAD, Global FUND, EU, USAID, FHI, KNCV TB foundation, CIFF, WHO STOP-TB….